To assess preliminary data on the effectiveness, particularly on HIV testing behaviors, of an entertainment-education radio serial drama, Makgabaneng.

Study Design

Cross-sectional study that began 18 months after the initial radio broadcast. Data were collected between February and May 2003 in face-to-face interviews by using a structured questionnaire in a multistage-sampling approach. A total of 1,730 households were selected; 38 (2.2%) were abandoned, 203 (12%) were unoccupied at the time of the fieldwork, and the residents in 23 (1.3%) refused to participate in the enumeration process to identify an eligible household member. Of the 1,466 households that were enumerated, 961 (65%) had eligible household members, and interviews were completed for 807 (84%). One person was randomly selected from each household and asked to participate in the interview. To explore different aspects of audience involvement in the radio program and identification with the characters, four measures of exposure to the program were assessed: a. how often respondents listened ("frequency"); b. how long they had listened ("duration"); c. whether they had spoken with anyone about Makgabaneng in the previous 3 months ("discussion"); and d. whether they were attentive to and engaged with key characters in story lines related to HIV testing ("identification").

Setting

Botswana, which in 2004 had an adult HIV prevalence of 25%, yet an estimated 300,000 people with the disease do not know they were infected. Botswana reports near universal (96%) access to radio.

Participants

Eligible participants were aged 15-49 years who could speak and understand Setswana and were living in the household during the time of fieldwork. Of the 807 respondents, 555 (69%) were currently or recently sexually active. Of these, 55% were female, 63% were 25 years of age or older, 36% had no formal education or had primary schooling only, 38% were currently married or cohabiting with a partner, and 73% were living in an urban area. Mean age at sexual initiation was 18 years.

Intervention

The Makgabaneng radio serial drama began being broadcast on the radio in 2001 as part of a government communications strategy for behavior change: Modeling and Reinforcement to Combat HIV (MARCH). Grounded in behavioral change theory, the MARCH strategy builds on two fundamental principles of behavior change: showing people how to change through role models (modeling) and supporting efforts to change primarily through interpersonal communication and normative change (reinforcement). The key elements of MARCH's modeling component are a. progression of change over time; b. use of entertainment education as a vehicle for modeling; c. use of contrast modeling in program content; and d. creation of character models similar to the target audience. MARCH programs are designed to be in place for a long time; the first several months are used to capture and retain a loyal audience by developing a compelling and entertaining program. Subsequently, behavioral models change their behavior over time, experiencing setbacks and facilitators along the way, changing attitudes and adopting steps toward behavior change until they change behavior. Activities to reinforce awareness of HIV include groups that listen to and discuss this serial drama, a magazine (Go Sharpo!), and communitywide activities, such as facilitated community meetings and road shows. All the program components address multiple objectives related to psychosocial factors and behavior change including increasing (a) positive attitudes toward and behaviors of abstinence, monogamy, and condom use; (b) knowledge and use of services to help prevent mother-to-child transmission of HIV; and (c) favorable attitudes toward HIV testing and motivation for testing. Makgabaneng is written, produced, and acted by residents of Botswana, and two new episodes have been aired weekly since 2001. Program content is reviewed by a technical advisory committee of local experts on content; additional guidance on behavioral change theory is provided by the CDC and technical support on drama production is provided by Media Support Solutions. The program story lines incorporate a village, a city, and a cattle post and depict current realities in Botswana. By February 2003, when data collection began for this assessment, Makgabaneng had begun to model the behavior change process for HIV testing in several story lines.

Outcomes

The primary outcome was HIV testing. Intermediate psychosocial and behavioral outcomes were included in addition to actual reports of HIV testing because the assessment was an interim evaluation conducted before the program was complete and because attention to both intermediate steps and final outcomes was considered the most appropriate approach to evaluating programs that model behavior change as a process. Intermediate outcomes included:

Stigma. Six statements were adapted from other work addressed stigmatizing attitudes. Respondents indicated their level of agreement on a 5-point scale ranging from "strongly agree" to "strongly disagree." Reliability analysis was performed, and one item was dropped because of low inter-item correlation. Thus, a five-item scale for stigma, created by averaging responses across all items (mean = 2.11, SD = .73, alpha = .74), was used to assess stigmatizing attitudes; higher scores indicated stigmatizing attitudes.

Intention. Respondents who reported never being testing for HIV were asked to rate how likely they were to have an HIV test in the next 3 months. The five possible responses ranged from "not at all likely" to "extremely likely."

Talking About HIV Testing. In relation to the most recent sexual partner, we asked respondents, "Have the two of you ever discussed getting tested for the AIDS virus?" Data on persons who had talked about testing were compared with data on those who had not talked about testing (referent).

Testing for HIV. Respondents were asked if they had ever been tested for HIV and if so, the month and year of the most recent HIV test. Data on persons tested during or after December 2001 (3 months after first potential exposure to the program) were compared with data on those who either were tested before December 2001 or were never tested (referent). Persons previously tested were included in the comparison group for two reasons: First, repeated HIV testing is important in a country where HIV prevalence among adults is 25% or higher. Second, it was unknown whether persons tested since December 2001 had also been tested previously but decided to test again.

Results

Nearly one half (46%, 243) of sexually active respondents reported listening to Makgabaneng one or more times each week, 15% (76) reported listening for 1 year or longer, and 19% (100) reported talking with someone about Makgabaneng in the past 3 months. In addition, 23% (122) of the respondents attended to the story line (i.e., spontaneously named any relevant character) and 9% (50) attended to and identified with relevant characters (i.e., spontaneously named one or more relevant characters and identified a relevant character as a favorite). Overall, the mean score for stigma was 2.11 on a scale of 5 which reflects low levels of stigmatizing attitudes. Twenty-two percent had been tested since December 2001. Of the 326 respondents who had never been tested, 27% reported no intention to test in the next 3 months, and 29% reported being extremely likely to test. More than one half (57%, 301) reported that they had talked with their partner about HIV testing gave a positive response.

Multivariate analyses were conducted controlling for a consistent set of demographic factors, and each model included only one measure of exposure to the program. HIV testing was not associated with any measure of program exposure in bivariate or multivariate models. Likewise, the exposure dimension of discussion was not associated with any of the outcomes.

Stigma Related to HIV. Frequency (beta -0.15 [-2.15; p<0.05]), duration (beta -0.26 [-2.71;p<0.01]), and identification (attentive and identified vs. not, beta -0.33 [-2.71; p<0.01]) all had statistically significant associations with HIV-related stigma. Greater levels of exposure to Makgabaneng, including more frequent listening, longer-term listening, and attentiveness to and identification with the characters, were associated with lower levels of stigmatizing attitudes.

Intention to Test for HIV. Both frequency and duration of listening were significantly related to a respondent's intention to test in the next 3 months. Respondents who reported listening to Makgabaneng one or more times each week were almost twice as likely (adjusted odds ratio [AOR] = 1.8; 95% confidence interval [CI] 1.18-2.86) as less frequent listeners and nonlisteners to have stronger intentions to have HIV testing. Likewise, compared with those who listened for less than 1 year or not at all, longer term listeners (=1 year) were twice as likely to have stronger intentions to be tested in the next 3 months (AOR = 2.1; 95% CI 1.01-4.55).

Talked With Partner About HIV Testing. Among the measures of exposure tested, only duration of listening had a statistically significant association with talking about HIV testing. Respondents who listened for 1 year or longer were more than twice as likely as those who listened less than 1 year or not at all to report talking to their partner about HIV testing (AOR = 2.45; 95% CI 1.17-5.16).

Conclusions

The authors concluded that the popularity of Makgabaneng combined with preliminary evidence of its effects on intermediate outcomes related to HIV testing suggest that the radio serial drama is a promising medium to facilitate behavior change in Botswana.

Quality Rating

There is no standardized measure of quality of cross-sectional studies. Nonetheless, the findings are subject to a number of limitations. The cross-sectional study design limits the ability to control for self-selection bias or to draw conclusions about the temporal relationships between listenership and HIV-related outcomes. However, two important structural factors influenced the study design. First, the program was broadcast on radio stations transmitting throughout the country, so random assignment to exposure was not an option. Second, collection of baseline data was prohibited when the program started, because a national census of Botswana was under way. The timing of the assessment also compromised the ability to detect certain associations. First, during the first 18 months of the Makgabaneng program, the national voluntary testing and counseling program was being established throughout the country, increasing the availability of HIV testing services overall. There is no way to evaluate the role of increased access to HIV testing centers in respondents' decisions to be tested. Second, although the assessment was designed to provide information on preliminary effects, including intermediate outcomes, the assessment was conducted before resolution of the behavior-change modeling process for one of the selected outcomes (reported HIV testing). For example, characters in story lines related to HIV testing had not yet been tested for HIV at the time of data collection. For these reasons, the full impact of Makgabaneng on HIV testing may be underestimated by this assessment.

In Context

A Cochrane review reported that mass media can be an effective intervention medium to promote HIV testing.(1) Results of this evaluation indicate that the radio serial is a promising medium to facilitate behavior change. Because the results are preliminary, additional evaluation of the strategy and program is warranted. Because of Botswana's 2004 adoption of an "opt out" approach to HIV testing, where HIV testing became a part of routine medical visits for nearly all patients unless they explicitly refuse,(2) additional evaluation of the impact of Makgabaneng on HIV testing behavior is not possible. However, story lines that emphasize other important outcomes, such as delaying sexual initiation and being faithful to one partner, offer additional opportunities to evaluate the role of Makgabaneng in changing behavior.

Programmatic Implications

In an era of competing demands on audience attention, limited public health resources, and frequent media messages related to HIV prevention, it is noteworthy that a program such as Makgabaneng can capture and maintain the attention, on a weekly basis, of a large audience at risk for HIV. Almost one half of all surveyed respondents reported frequent listening to Makgabaneng. This finding suggests that the program has broad reach and appeal for the target audience. Having an audience who consistently tunes in to a program provides public health practitioners with a regular opportunity to communicate with the audience, to introduce relevant information, to promote available services, to address emerging problems, and to model new behaviors and norms.